If you or your patient/ relative have faced any adverse drug experience, please fill the following form for us to serve you better.

    Who are you?

    What's your complaint?

    Your details
    Details of the patient
    I, the patient/ reporter, provide my consent to Senores Pharmaceuticals to contact me via

    Details of the Product being reported
    Describe the adverse drug experience(s) or your product quality complaint(s)

    What has been the outcome of the adverse drug experience(s)?

    Did any of the following occur as a result of the adverse drug experience(s)?

    Please provide the medical history of the patient

    Disease/ Disorder
    Disease/ Disorder
    Disease/ Disorder
    Is the patient taking any other medications?

    If yes, provide the details of the other medicines
    Drug 1
    Drug 2
    Drug 3
    Drug 4
    Drug 5
    Drug 6
    Would you like to share any other information related to the case?